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Humana

Medicare-focused (no employer commercial book) · updated August 8, 2026

Coverage right now

Humana exited employer-group commercial medical (completed ~2024) — treat 'Humana commercial' as N/A; several consumer sites erroneously describe active plans. Its Part D formularies exclude weight-loss GLP-1s (statute), covering CV/MASH/OSA indications with PA on some formularies. Unusual dual role: Humana is CMS's central processor for the Medicare GLP-1 Bridge (BIN 028918, PCN MEDDGLP1BR), adjudicating $50 Bridge claims for all Medicare beneficiaries nationwide.

Drug status

DrugStatusDetailConfidence
Zepbound® (tirzepatide)Excluded Part D weight-loss exclusion; OSA-indication coverage possible with PA on some formularies. KwikPen covered under the Bridge from 7/1/2026. sourcemedium
Wegovy® (semaglutide injection)Excluded Part D weight-loss exclusion; CV-risk-reduction indication coverable with PA (plan attests not-for-weight-loss). All formulations covered under the Bridge. sourcemedium
Foundayo™ (orforglipron)Excluded
from Jul 1, 2026
Not Part D-covered for weight loss; fully covered under the Bridge at $50/month. sourcehigh
Saxenda® (liraglutide)Excluded Not in the Bridge; Part D exclusion applies. sourcehigh
What preferred, covered and exception only mean
Preferred
On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
Covered
On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
Non preferred
On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
Exception only
Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
Excluded
Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
Varies
The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
Unknown
Not yet verified against a primary document. Recorded as absent rather than guessed.
N/A
Not applicable to this payer.

Prior authorization criteria

medium
PA required
Yes for indication-based Part D coverage (CV/MASH/OSA) — the plan verifies the drug is NOT for weight loss. The Bridge replaces plan PA with prescriber attestation to a BMI category.
Initial BMI
Bridge categories: BMI >= 35 (no comorbidity needed); BMI >= 30 with HFpEF, uncontrolled hypertension, or CKD >= 3a; BMI >= 27 with pre-diabetes, prior MI, stroke, or symptomatic PAD.
Comorbidities
Per Bridge categories; Humana PA also screens MTC/MEN2 history.
Lifestyle requirement
Bridge: attestation of 'current and ongoing lifestyle modification' — no program documentation required.
Initial authorization
Bridge PAs valid through Dec 31, 2027. Humana indication-based PAs: not published (secondary: 6-12 months).
Reauthorization
Not applicable to CV/OSA indication coverage.
Step therapy
None documented for CV-indication Wegovy.
Quantity limits
Not published in retrieved documents.

Primary criteria document:cms.gov

Exceptions and appeals

Appeal deadline
65 days
Deadline detail
65 calendar days from the coverage-determination notice (changed from 60 on Jan 1, 2026 — most guides are stale).
Exception route
Part D coverage determination via Humana Clinical Pharmacy Review 1-800-555-2546 or CoverMyMeds. Bridge claims bypass the plan entirely.
Turnaround
Part D coverage determination: 72h standard / 24h expedited. Redetermination decision: 7 days standard / 72h expedited.
Where
Per your Humana denial letter.

Source:cms.gov

Dated changes

  • Jul 1, 2026 Medicare GLP-1 Bridge live — Humana is the national central processor source
  • Apr 21, 2026 BALANCE Part D component indefinitely delayed; Bridge extended through Dec 31, 2027 source
If you have Humana Part D and want a GLP-1 for weight loss: the Bridge is the route, not a plan appeal. If you have T2D, OSA, or MASH, standard Part D with the indication-based PA is the route instead.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.